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Inequity in the Quality of Care in the Thai Health Care Reform Context: The Consumer’s Perspective

Siriwan Grisurapong Address: Associate Professor, Faculty of Social Sciences and Humanities, Mahidol University, Salaya, Nakhonpathom 73170, Thailand

Keywords:

equity, quality of care, Thailand, 30 Baht Universal Coverage Program

Abstract
Inequities in health status and access to health care among different socioeconomic groups in the Thai population have been increasingly documented during the past decade, but little is known about inequities in the quality of care. This paper examines inequities in the quality of care in the context of Thai health care reform, particularly the 30 Baht Universal Coverage Program that was introduced in 2001. To provide information about the impact of health care reform on the quality of care, data were collected in Nakhonpathom province by means of a questionnaire survey. Six hundred and fifty individuals aged 18 years or more were interviewed concerning their perceived health status, their utilization of health care services and the quality of care received. The consumer’s perspective was measured in terms of satisfaction with health care services, choice of available health care services, ability to understand the written instructions on medical prescriptions and the printed information distributed by health care personnel, and, lastly, the quality of communication between physicians and patients. The findings are that lower income groups rated their health status more negatively than did the higher income groups, utilized more health care services than the higher income groups, had fewer choices in terms of where to go for medical care, and rated their understanding of the information distributed by health care personnel and the instructions written by pharmacists on prescription medicines more negatively. Moreover, their understanding of what the physician said was rated more negatively and they had fewer opportunities to ask questions and to become involved in decision making with the physician. Despite the coverage of preventive services of the Universal Coverage Program, the lower income groups utilized these services significantly less than their counterparts in the higher income groups. These results indicate that although improvements in the quality of health care in the context of the Universal Coverage Program in general may be necessary, such improvements are not sufficient to guarantee equity in the quality of care between different socioeconomic subgroups.

the health status of the Thai population has been gradually improving as can be seen from the IMR. 1999). low and high income groups. However. there are some problems with these existing health insurance schemes regarding coverage and eligibility as well as the quality of care in LICS. males and females.Background During the past few decades. the Voluntary Health Card Scheme (VHCS) and the Low Income Card Scheme (LICS) and private health insurance. which covers employees working in the formal sector.8 to 71. Pannarunothai (2001)). The Universal Coverage Scheme was introduced in 2001 and expanded to all health facilities in 2002. inequities in health status between urban and rural areas. Several health insurance programs had been developed in Thailand for different population groups such as the Civil Servants Medical Benefits Scheme (CSMBS). which reduced from 125 in 1960 to 30. more efforts are needed to identify which interventions will be most effective and in which areas. and different regions have been noted (Kakwani & Phothong (1999). Inequities in health care utilization and health care expenditure (Makinen et al (2001).4 in 1990 to 66. the Social Security Scheme (SES).7 for females (Health Statistics.7US$) Universal Health Insurance Coverage Program which is generally referred to simply as the 30 Baht Scheme. Now VHCS and LICS have changed into the 30 Baht (. Life expectancy has increased from 66. These studies showed large differences in health care utilization between people who live in urban and rural areas. Pannarunothai & Mills (1997).9 in 1995 for males and from 70. which covers all civil servants and some of their family members. All those who are not covered by any other health insurance scheme are eligible for the Universal Coverage Program. individuals who are not covered by any scheme can ask for a fee waiver from the health care facilities they visit. They also documented that people in the lower income groups paid a larger proportion of their income for health care compared to those in the higher income groups. However. Although government health policies have tried to reduce these inequities. 1995). the rapid increase of expenditure in CSMBS etc (Suphachutikul. Although all these health insurance schemes only covered approximately three quarters of the Thai population.5 in 1995. Each individual registers with a public or private health 2 . Pannarunothai (2000)) have also been reported.

This 30 Baht Scheme includes most health care services except cosmetic surgery. obstetric delivery beyond two pregnancies. treatment options etc.404 Baht. 2002). the card holders can access any public health care facility. treatment of drug addiction and chronic psychological illness. Most studies have focused on improvements in health care or the quality of care in terms of clinical components. the annual per capita payment rate is 1. infertility treatment and some other very expensive treatments (NaRanong & NaRanong. Methods Nakhonpathom Province. there have been very few studies of the quality of care in Thailand. This study was designed to explore inequities in the quality of health care services and describe the inequities in terms of health status and health service utilization in order to assess the impact of the Universal Coverage Program.facility that has joined this initiative with the government and then they receive a gold card to use when seeking health care services from the facility. In order to cover respondents both in the urban and rural areas. Each visit to a health care facility requires a co-payment of 30 baht. located in the central region of Thailand. A district has been selected from each group. Those living in rural areas and wishing to utilize health services have to start from the local health center or the nearby hospital and then follow a referral system if they wish to use the services of a provincial or tertiary-care hospital. The Ministry of Public Health will provide a budget to co-operating health care facilities by capitation according to the number of individuals registered with them. was purposively selected as the site of this study. however. From the consumer’s perspective. In case of emergencies. and on the perimeter of Bangkok. Collins et al 2002)). In order to achieve a high quality of care from both the health care personnel's and the consumers' points of view a good understanding of the existing situation of the quality of care is necessary. One of the main focuses of the30 Baht Scheme is the provision of quality health care for all users. Currently. But consumers want more from health care facilities than simply better technical or clinical components. population density and infrastructure into 2 groups. So far. The same procedure has been employed 3 . But those living in urban areas can register directly with a provincial or tertiary-care hospital. organ transplants. all districts in the province were classified according to their economic characteristics. good quality means providing care and information in a way that works for them at the time they want it (Davis (2002. They want trustworthy information on their conditions. hemodialysis.

only one individual. utilization of health care services in the past year (classified into OPD visit and hospital admission). having experience or knowledge of any medical errors. but these villages were not included in the study. regular utilization of other types of health care facilities and utilization of preventive care services. The data collected consist of general socioeconomic characteristics of the respondents.7). All were trained in field survey and interview techniques before going to the field. refined and tested for reliability (Alpha-Cronbach = . being given sufficient time explanation as needed by physicians and understanding what the physician said. It was then adjusted. self-reported health status. the head or the representative of the household was interviewed. confidence in the quality of future health care. Households were selected by systematic proportional sampling in order to get 10 percent of the population from 2 selected districts. Perception of quality of health care is measured in terms of satisfaction with health care services utilized in the past 2-5 years. having regular doctors and a choice of available health care services. Quality of communication with physicians was measured in terms of whether the doctor was thought to be a good listener. utilization of alternative medicine in the past 2 years. Descriptive statistics and Chi-square techniques have been used in the analysis. The questionnaire was pretested in 2 villages with characteristics similar to those of the selected districts. 650 households were interviewed. In total. Before the start of the fieldwork. belief that they would receive better treatment if their socioeconomic status was higher. village health volunteers and community leaders were contacted to coordinate the visits of the interviewers with the heads or representatives of the households that would be interviewed. From each household. The interviews were conducted between August and September 2002. 4 .to sampling subdistricts and villages. Analysis was carried out using SPSS version 11. and confidence in the physician. Interviews were conducted by means of a structured questionnaire. Data were entered and checked for errors. whether they were given the opportunity to ask questions and be involved in decision making. The interviewers consisted of 6 health officers and post-graduate students from the Faculty of Social Sciences and Humanities. understanding of the written instructions on prescription medicines and printed information distributed by health care personnel. non-compliance with the physician’s instructions. Mahidol University. being treated with respect.

5 percent of the sample had no insurance. respondents in the second lowest income quintile gave a more negative rating of health status than did respondents in the lowest quintile. If we look from the supply side.000 baht per month. The same picture was found for the rate of admissions to hospitals (α = . Surprisingly.Results Sixty-four percent of those interviewed in this study are female. The highest income quintile reported regular use of health facilities such as private hospitals and private clinics although the rate of service utilization for these facilities in the lowest income quintile is the second largest. Fourteen percent are housewives and 9 percent are unemployed. (Table 2) Quality of Care The perceived quality of care will influence the consumer’s decision to seek care. Fifty-four percent of the interviewees reside in urban areas whereas 46 percent reside in rural areas. Twenty percent have no income and almost half have an income less than 5. Fifteen percent of the two lowest income quintiles reported having used inpatient services whereas only 5 percent of the highest quintile used these services. The majority of respondents are in the age range 30-49 years and three-fourths are married.00 level. the low income quintiles used Out-Patient Department (OPD) services more than did the higher income quintiles (α = 0. reflects the opinion of each social group of their health care services. The majority is under the Universal Coverage Program. The difference in choice of health facilities was significant at the 0. (Table 1) Health Status and Health Care Utilization More respondents in the highest income quintile group rated their health status “Excellent/good” compared to any other quintile. Most of them are owners of small businesses and employees. However. Sixty-seven percent of the respondents have completed primary education.00 level. therefore. and the utilization rate for these types of health facilities is highest in the second lowest quintile. The lower income quintile groups tended to use services in health stations and district hospitals. The types of health facilities that have been regularly used by each income quintile group also demonstrated differences in accessibility to different levels of quality of services. Differences in self-reported health status were significant at the 0. In terms of utilization of health care services. The perception of quality of care. the quality of services offered to consumers with the same needs may vary systematically with social groups. Table 3 shows that respondents in the low income quintile groups tend to be more satisfied with the health 5 . Ninety-five percent of respondents are covered by some health insurance scheme.05).01).

00). 9-16 percent of respondents reported that they had personally experienced medical errors. Although the third income quintile had the lowest positive response rate. it can be noted that few respondents make regular visits to doctors. An important factor that can influence the outcome of health care is the patient's understanding of the instructions written by pharmacists on prescription medicines. but 12-23 percent of respondents in all groups reported non-compliance.7-69. (α = 0.6 percent of all respondents in each quintile. although there is no significant difference. positive responses ranged from 54. It was noteworthy therefore that it is about 20 percent of all respondents reported some use of alternative medicine services. It was found that there is a significant difference in understanding among social groups (α = 0. although there is no significant difference among income quintile groups. When asked about their confidence in the quality of care that they are likely to receive in the future. More respondents in the highest income group compared to any other group responded positively when they were asked if they understood the instructions on prescriptions.care services they utilize than the high income quintiles.00 ). Having a regular doctor was taken as an indicator of how good accessibility to health care services is in each social group. or their family members had experienced 6 . When asked about non-compliance with the physician’s instructions. When we asked about this. there is no significant difference among income quintile groups. More than half of the respondents believed that they would receive better treatment if their socioeconomic status was higher. the difference between this group and other groups is not so great. When asked about the choice of health care services available to them. The second quintile had the lowest number of positive respondents. it was found that less than 20 percent of all respondents in all income quintiles had regular doctors.01). Although there is no significant difference. The results were similar for understanding of printed information and health care instructions distributed by health care personnel (α = 0. It is noteworthy that all groups used herbal medicine. more respondents in the higher income groups reported use of alternative medicine compared to the lower income quintiles. Although there is no significant difference among income groups. Regarding medical errors related to prescriptions or hospital treatment. Utilization of alternative medicine may indicate some cultural belief or preference to stay away from prescription medications and other modern medical practices. the richest group of respondents (the fifth quintile) reported more positively than any other group and respondents in the second quintile responded more negatively than any other group.

A similar picture was found for cholesterol screening. third and fourth quintiles were 8. The figures for the other quintiles were as follows: fifth quintile (23. Surprisingly.5 percent). third and fourth quintiles were 8.0. twice the rate for the first quintile. cholesterol and dental screening and blood examination. Forty-three percent of the females in the highest income quintile reported having undergone cervical cancer screening. which is 2 times higher than the figure for the lowest income quintile.3 and 11. fewer respondents in the second. Although the number of respondents in each quintile who reported utilizing prevention services seemed to be fewer after the introduction of the Universal Coverage Program. α = 0. whereas the figure for the first quintile was 16 percent. When asked if they had been screened for cervical cancer.00 and α = 0.13. Although more respondents in the higher quintiles reported utilizing this service compared to the lower quintiles it is notable that respondents in the second quintile made least use of this service.05. followed by the first quintile (31 percent). the utilization rate for the fifth quintile was 23 percent. the fourth quintile (24 percent) and the second quintile (22 percent). With regard to dental screening. The rates for the second. respectively. For cholesterol screening. had received a physical check-up and had their cholesterol levels tested before the Universal Coverage Program was introduced. respectively.01.them or they had heard of someone in their community having experienced them. there were significant differences in the rates reported (α = 0.5 percent. respectively. 25 percent of the highest income quintile received this service.8. 7 . There is no significant difference among income groups. whereas the figure for the fifth quintile was 38 percent.0 percent. In this case the figure for the fifth quintile was 20 percent.1 and 13. The figures for the second. For utilization of blood examination services.2 percent). The corresponding figure for the highest quintile is 26 percent. which is almost the same rate as the lowest income quintile (24 percent). Good quality of care should include preventive care. Respondents in the third quintile reported the lowest rate for physical check up (18 percent). physical check-up. the rate for the first quintile was higher than that of any other quintile (30. 7. The second quintile also made least use of physical check-up services whereas 53 percent of the fifth income quintile and 39 percent of the lowest quintile reported using them. third and fourth quintiles utilized cervical cancer screening services compared to the lowest quintile (14 percent). a significant difference among the different income quintiles has been found for utilization of cervical cancer screening.

more respondents in the highest income quintile answered positively compared to lower quintiles.whether the physician was a good listener. (Table 4) From the consumer's point of view. being treated with respect. and the physician spending sufficient time and explaining as necessary . Discussion Very little research has been carried out in Thailand related to the quality of care from the consumer’s viewpoint. What consumers also want is information about their health conditions. When asked about other components of the quality of communication between physicians and patients . The results of the survey show that more respondents in the fifth income quintile were given an opportunity by their physicians to be involved in treatment decision making compared to the lower quintiles. third (16. Although perceived health status has been considered a personal perception (Evans et al. However. This study demonstrates that health care intervention programs that aim to increase accessibility by reducing of financial barriers may still face problems of equity in the quality of care. it has frequently been used in studies related to the issue of health equity (Manderbacka (1998). although more respondents in higher income quintiles responded positively. This study corroborates the finding of earlier researchers that Thai people in the lower income groups tend to perceive their health status more negatively than do higher income groups (Pannarunothai & Mills. If the rate of health care utilization is used as an indicator of health status. quality of care implies more than the technical competency of health professionals. and the available treatment options.fourth quintile (21. This paper demonstrates that perceived health status can be used as an indicator to identify differences in health status among different social groups. 1997). Gao et al (2002)).there was no significant difference among respondents in the different socioeconomic groups. although the difference is only slight.4 percent).8 percent) and second quintile (15. 2001) that may have limited value as an indicator of health status. having confidence in the physician.9 percent). Thus good communication between physician and patient is essential. When asked if they understood what their physician had said and whether their physician gave them the opportunity to ask questions. the findings from this 8 . the figure for respondents in the second and third quintiles was lower than that for the first quintile.

The large majority of the poor use the services of health stations and district hospitals whereas the rich use the services of private clinics and private hospitals. The findings from this study demonstrated that respondents in different income quintiles reported differently in terms of their understanding of what physician said and in terms of having the opportunity to ask questions and be involved in decision making. strategies to increase their accessibility and utilization should be considered. improvement in choices of health care facilities. the rate of utilization of preventive services did not increase as expected. Quality of care also means comprehensive care. The findings of this study demonstrated that only a small proportion of the respondents utilized these services and that people in the lower quintiles utilized them less than those in the higher quintiles. If equity in the quality of care is one of the goals of government health policy. Accessibility and utilization of preventive care services reflects the quality of health service coverage. People living in rural areas have to register with rural health stations and district hospitals that may not be able to provide the same quality of health services as those found in urban areas. as more respondents in the low income quintiles reported that they have fewer choices for health care visits compared to respondents in the higher quintiles. which is a component of quality of care. After the implementation of the Universal Coverage Program . Good communication between physicians and patients can lead to good health outcomes. The findings suggest that quality of care in terms of communication between physician and patients can be improved not only in terms of the quality of communication itself. then the findings of this study suggest that the way the Universal Coverage Program is being implemented may make the policy unrealizable. 9 . Since preventive services are cost-effective. including preventive care services. Pannarunothai (2002) also found that the Universal Coverage Program did not change or increase the rate of utilization of preventive services. The Universal Coverage Program should therefore allow consumers to register with any health facilities they choose as this may reduce inequity in quality of care. particularly for rural people. should. although preventive care services are included in the coverage.study also show the same picture that the poor tend to have a more negative opinion of their health and use more outpatient and inpatient services than do higher income groups. be a target of the Universal Coverage Program. Moreover. but also in terms of the quality of communication with each specific subgroup of the population.

equity in quality of care among people in different socioeconomic groups should also be taken into account. may still be restricting the choices of the lower income groups. the differential response rates of the various socio-economic groups suggest that. When communication between physicians and patients was examined. 10 . in general. especially for the low income group. Conclusions Although equitable accessibility to health care services is a main focus of the Thai health service system. and the health care instruction given in person. this study showed that in terms of understanding the instructions on prescription medicines and written information distributed by health care personnel lower income groups were less positive than the higher income group. the lower income groups reported more negatively than the higher income groups in terms of understanding what their physician said and in terms of being given the opportunity to ask questions and be involved in decision making.Although respondents in each quintile reported positively when asked if they understood the instruction on prescription medicines . However. information needs to be communicated more effectively. Quality of care in terms of comprehensive services provided showed that the lower income groups had lower utilization rates for preventive services than the higher income groups. the printed information distributed by health care personnel. The Universal Coverage Program did not increase rates of utilization of these services although it may be too early to conclude anything since this new scheme is still quite new. Further studies in quality of care should focus not only on the clinical and technical components of health care but also on communication with health care personnel from the consumer’s perspective. which allows beneficiaries to use services from those health facilities with which they have registered. it may not ensure equity in the quality of care. The lower income consumers tended to use services from health stations and district hospitals whereas the higher income group tended to use services from private clinics and hospitals. All these findings suggest that there is some room to improve the quality of care. With little information on the quality of care from the consumer’s perspectives in Thailand. The 30 Baht Universal Coverage Program. Clear understanding of written information and instructions on prescription medicines could lead to better health outcomes among the poor and contribute to reducing inequity in health status and health care services.

“How do respondents understand survey questions on illhealth?” European Journal of Public Health. pp1781-90 Pannarunothai S. Diverse communities. 2002. Center for Health Equity Monitoring. Indicators on well being and policy analysis newsletter. 2000. 2002. Doty MM. Rauch M. NaRanong A. 2001. Pannarunothai S. Health System Research Institute. Center for Health Equity Monitoring. Equity in Health. Bitran R. Thailand 11 . McIntyre D. 1997 “The poor pay more: Health-related inequality in Thailand. Walters H. “Inequalities in Health Care Use and Expenditures: Empirical Data from Eight developing Countries and Countries in Transition” Bulletin of the World Health Organization. 2000. Ubilla G and Ram S. Possibilities and Choices in Establihing Universal Coverage Program. 2000. Pattamasiriwat D and Srithamrongsawat S. 1998. (in Thai) Makinen M. New York. 3(3). the Commonwealth Fund. Thailand (in Thai) Pannarunothai S & Mills A. Health Care Reform Project Supachutikul A. et al. March 2002 Davis K.” Social Sciences and Medicine. “Challenging inequity in health: From ethics to action” Oxford University Press. Ives BL. Diderichsen F. Assessment of Universal Coverage Program year 1 (2001-2002). et al. Gilson L. Prieto AL. Edwards JN. The quality of American health care: Can we do better? President’s message. Hughes DL. September 2000 Pannarunothai S. Nareseaun University. Nareseaun University Pannarunothai S. 2002. Nonthaburi. Whitehead M. p51 Gao J. 2002. 8. 2000. p 20-29 Health statistics.1999 “Health status and nutritional status of Thai population”. pp1-23. Kakwani N. Almagambetova N. Situation analysis on health insurance and future development. Health System Research Institute. 17 suppl December. Macro-economic Indices for Measuring Equity in Health Finance and Delivery 1986-1998. 44(12). common concerns: Assessing health care quality for minority American. pp 319-24 NaRanong V. 78(1): 55-65 Manderbacka K. Pattamasiriwat D. “Health equity in transition from planned to market economy in China” Health Policy and Planning.1999. Nonthaburi. Phothong J.References Collins KS. July. 1995. Research Report. Bhuiya A and Wirth M. the Commonwealth Fund Evans T.

2) 16 ( 2.Table 1 Socioeconomic and demographic characteristics of the sample Characteristics Sex -Male -Female Age (years) -Up to 29 -30-39 -40-49 -50-59 -60 up Marital status -Single -Married -Separated.8) 497 (76.0) 163 (24.000 -5.0) 34 ( 5.000 -10.9) 128 (19.4) 52 (8.3) 137 (21.2) 88 (13.2) 616 (94.7) 16 ( 2.0) 350 (53.0) 133 (20.5) 55 ( 8.2) 48 ( 7.4) 437 (67. widow Educational level -Illiteracy -Primary school -Secondary school -Certificate & degree Occupation -Employee -Agricultural workers -White collar workers & civil servants -Owners of small business -Housewife -Unemployed Income (Baht) -No income -Below 1.001-10.4) 314 (48.4) 104 (16.0) 86 (13.000 -1.1) 52 (8.6) 33 ( 5.0) 70 (10.5) 131 (20.2) 12 .0) 6 ( 1.2) 113 (17.8) 61 ( 9.5) 196 (30.2) 415 (63.4) 31 ( 5.001-5.4) 170 (26.8) 546 (88.8) 300 (46.2) 182 (28.000 up Residence -Urban -Rural Under coverage of any health insurance schemes -Yes -Universal coverage -Civil servant -Social security -Private insurance -No Number (%) 235 (36.

00 ** Chi square test significant at 0.4 576 88.6 *** Chi square test significant at 0.1 6 4.7 8 6.5 101 15.0 18 13.9 Fourth 67 51.9 131 76 55.0 2 1.6 2 1.4 25 18.7 47 34.5 22 16.6 264 40.9 138 428 65.5 Overall 311 47.7 81 12.8 19 13.6 Fifth 87 63.9 34 30.4 40 35.0 61 46.7 56 42.Were you admitted to hospital in the past year? * -Yes 20 15.2 25 19.3 137 84 64.1 54 41.6 32 24.0 14 12.8 5 4.1 47 35.1 113 90 65.Table 2 Self-reported health status and utilization of health care services classified by income quintiles Self-reported health status and utilization of health care services First -Please give a self-assessment of your health status *** -Excellent/good -Fair -Poor -Did you visit any outpatient health facilities in the past year? ** -Yes -No -Overall 68 51.2 119 90.4 52 46.8 258 39.4 9 6. 6 23 3.1 17 13.3 -No 111 84.6 40 29.5 60 53.2 650 -What type of health care facilities do you regularly use? *** -Private clinics -Health stations -District hospitals -Provincial/regional/tertiary hospitals -Private hospitals 32 24.1 119 86.3 60 43.6 43 31.7 121 18.1 131 94.0 55 40.8 222 34.1 21 16.0 5 3.4 18 13.5 .0 96 85.05 13 .4 131 79 69.2 10 7.1 21 16.6 5 3.01 * Chi square test significant at 0.9 74 11.1 62 44.8 7 5.9 42 32.2 141 21.7 17 15.5 99 75.0 42 30.1 22 19.5 Third 58 42.4 14 10.8 45 32.2 37 27.0 Income quintiles Second 31 27.9 12 9.

0 546 84.4 418 64.2 9 6.4 2 6.3 232 35.8 117 95.Table 3 Perception of quality of health care services Perception of quality of heath care services First -Are you satisfied with the health care services you received in the past 2-5 years -Satisfied -Not satisfied Income quintiles Second Third Fourth Fifth Overall 123 96.3 108 78.0 -How much choice of where to go for health care services do you have? *** -Adequate/would like more choice -No/little choice 97 75.6 42 30.3 107 81.7 7 4.4 103 74.4 44 33.9 3 8.7 37 34.6 117 85.3 27 84.5 91 80.2 94 71.1 131 98.3 -Do you have confidence in the quality of care you will receive in the future? -Yes -No -Do you visit doctors regularly? -Yes -No 87 66.5 100 88.2 133 20.4 13 12.5 32 23.1 99 93.8 105 80.1 96 69.8 -Did you utilize alternative medicine in the past 2 years -Yes -No 26 19.4 38 33.8 104 16.2 22 19.5 2 1.8 35 25.2 14 .2 71 65.8 13 10.3 1 2.6 37 28.6 3 8.6 -Have you ever used any of the following types of alternative medicine? -Herbal medicine -Acupuncture -Traditional medicine -Others 15 55.6 3 11.5 506 79.2 576 93.2 10 6.2 6 4.7 39 6.6 20 13.6 123 93.1 7 25.8 32 5.6 4 11.4 105 76.4 4 18.1 1 2.4 17 77.7 13 11.5 584 94.4 498 76.8 29 21.4 115 75.5 13 9.9 46 35.3 3 8.5 6 4.6 -Do you usually understand the written instructions on prescription medicines ? *** -Yes -No 119 95.2 106 82.8 105 80.8 90 87.2 23 17.9 5 4.6 152 23.7 62 45.4 26 19.9 2 7.9 4 3.2 1 4.2 21 15.6 75 54.6 126 95.2 117 84.5 3 9.6 75 66.5 118 95.9 114 89.8 27 77.8 31 24.3 85 64.4 7 6.8 124 90.7 24 18.5 20 14.1 6 4.3 29 80.

Do you usually understand the information distributed by health care personnel? ** -Yes -No -Have you ever failed to comply with your physician’s instructions? -Yes -No 113 95.2 *** Chi square test significant at 0.0 24 4.3 97 70.7 108 78.6 106 77.0 118 97.0 23 16.0 27 20.8 528 81.1 76 56.8 105 16.01 15 .5 14 10.5 100 88.6 104 79.8 12 9.2 268 42.4 21 16.0 467 71.4 78 12.3 46 35.2 -Do you believe that you would receive better treatment if your socioeconomic status was higher? -Yes -No -Have you or a family member had experience of any medical errors.7 73 56.0 110 84.2 100 73.4 27 20.1 13 11.0 130 97.9 44 41.3 24 17.5 2 1..6 17 12.7 58 43. or have you heard about any from a member of your community? -Yes -No -Not sure 63 50.0 83 63.0 63 50.4 86 76.0 30 21.1 18 13.0 4 3.5 31 22.2 101 77.3 122 18.7 14 12.4 13 11.0 63 58.3 83 64.8 5 4.8 21 16.2 57 43.0 10 10.2 90 90.8 358 57.5 3 2.5 583 96.5 132 98.00 ** Chi square test significant at 0.

9 24 17.4 15 11.7 96 73.5 17 13.2 14 14.9 260 40.2 172 26.0 7 8.2 21 26.1 35 25.8 23 16.05 16 .0 16 12.2 120 28.5 345 53.7 *** Chi square test significant at 0.8 25 29.1 483 74.1 62 54.9 99 -Blood pressure screening 75.5 74 56.9 11 18.3 129 19.5 21 16.9 18 15.3 27 20.7 35 25.3 33 29.4 40 30.7 71 51.4 42 -Dental check up 32.3 22 16.5 25 22.4 28 20.4 52 39.00 ** Chi square test significant at 0.6 59 -Blood examination 45.Table 4 Utilization of preventive care before and after universal coverage program Utilization of preventive care First Preventive services (Before Universal coverage program) 51 -Physical check up * 38.5 267 41.6 32 -Cholesteral screening * 24.1 83 12.8 31 23.3 32 23.3 18 13.9 9 8.2 99 72.3 28 21.5 27 23.1 10 10.0 10 8.9 110 79.3 32 23.4 47 34.3 141 21.4 79 69.01 * Chi square test significant at 0.1 34 43.7 70 53.8 93 14.0 60 43.9 13 11.8 190 29.6 10 7.4 52 37.9 52 39.0 Second Income quintiles Third Fourth Fifth overall 40 35.3 55 13.2 51 37.5 29 30.9 56 40.6 39 29.8 3 4.7 73 52.1 21 -Cervical cancer screening ** 21.5 68 49.0 Preventive services (After Universal coverage program) -Physical check up *** -Blood pressure screening -Cholesteral screening ** -Dental check up ** -Cervical cancer screening *** -Blood examination * 40 30.

2 19 16.9 25 22.2 43 32.5 13 11.2 22 16.7 83 60.9 4 3.8 114 82.2 452 69.7 630 96.1 4 2.9 111 98.9 20 3.5 88 64.4 523 80.4 123 89.3 16 11.7 106 76.9 -No 29 22.6 Fourth 109 83.8 127 96.1 15 10.7 100 88.1 86 76.5 113 86.4 23 17.5 121 88.1 136 98.9 522 80.Does the physician spend enough time with you? -Yes 102 77.3 56 42.3 18 13.6 11 8.8 59 52.2 49 35.4 133 97.9 4 3.2 71 51.1 108 82.0 18 13.8 Fifth 111 80.1 .7 -Do you usually understand what the physician says? -Yes -No -Do you have confidence in the physician? -Yes -No -Does the physician give you the opportunity to ask questions? -Yes -No 105 80.2 5 3.6 2 1.3 35 26.7 109 83.1 4 2.8 66 48.3 27 19.9 127 96.Does the physician give you the opportunity to be involved in decision making? -Yes -No 126 96.4 630 96.7 54 47.2 17 .1 88 67.9 7 5.8 108 95.3 128 19.3 128 19.9 29 22.5 39 34.9 345 53.8 130 94.8 74 65.8 Third 106 77.1 305 46.2 75 57.1 55 39.1 62 47.Does the physician explain your health condition to you satisfactorily? -Yes -No # Chi square test significant at 0 .7 120 91.7 3 2.6 128 97.9 577 88.4 31 22.1 27 23.8 103 75.1 110 80.1 88 77.5 -Does the physician treat you with respect? -Yes -No .9 .6 5 4.2 26 19.8 32 23.6 24 17.2 2 1.Table 5 Quality of communication with physician Quality of communication First -Does your physician listen well? -Yes -No 102 77.1 Income quintiles Second 94 83.5 198 30.2 34 24.2 22 16.6 Overall 522 80.3 120 87.3 69 52.9 20 3.0 134 97.5 127 19.8 73 11.4 27 19.8 96 73.